Acceptability, feasibility and costs of universal offer of rapid point of care testing for HIV in an acute admissions unit: results of the RAPID project

OBJECTIVES

UK guidance recommends that acute medical admissions are offered an HIV test. Our aim was to determine whether a dedicated staff member using a multimedia tool, a model found effective in the USA, is an acceptable, feasible, and cost-effective model when translated to a UK setting.

METHODS

Over 4 months in 2010, a health advisor (HA) approached 19-65-year-olds at a central London acute medical admissions unit and offered a rapid HIV point of care test (POCT) with the aid of an educational video. Feasibility and acceptability were assessed through surveys and uptake rates. Costs per case of HIV infection identified were established.

RESULTS

Of the 606 eligible people admitted during the pilot, 324 (53.5%) could not be approached or were individuals for whom testing was deemed inappropriate. In total, 23.0% of eligible admissions had an HIV POCT. Of the patients who watched the video and had not recently been tested for HIV, 93.6% (131 of 140) agreed to an HIV test; four further patients had an HIV test but did not watch the video. Three tests (2.2%; three of 135) were reactive and all were confirmed HIV positive on laboratory testing. HIV testing in this setting was felt to be appropriate by 97.5% of individuals. The cost per patient was £21, and the cost per case of HIV identified was £1083.

CONCLUSIONS

Universal POCT HIV testing in an acute medical setting, facilitated by an educational video and dedicated staff, appears acceptable, feasible, effective, and low cost. These findings support the recommendation of HIV testing for all medical admissions in high-prevalence settings, although with this model a significant proportion remained untested.

Insights into the pathophysiology of catch-up compared with non-catch-up growth in children born small for gestational age: an integrated analysis of metabolic and transcriptomic data

Small for gestational age (SGA) children exhibiting catch-up (CU) growth have a greater risk of cardiometabolic diseases in later life compared with non-catch-up (NCU) SGA children. The aim of this study was to establish differences in metabolism and gene expression profiles between CU and NCU at age 4-9 years. CU children (n=22) had greater height, weight and body mass index standard deviation scores along with insulin-like growth factor-I (IGF-I) and fasting glucose levels but lower adiponectin values than NCU children (n=11; all P<0.05). Metabolic profiling demonstrated a fourfold decrease of urine myo-inositol in CU compared with NCU (P<0.05). There were 1558 genes differentially expressed in peripheral blood mononuclear cells between the groups (P<0.05). Integrated analysis of data identified myo-inositol related to gene clusters associated with an increase in insulin, growth factor and IGF-I signalling in CU children (P<0.05). Metabolic and transcriptomic profiles in CU SGA children showed changes that may relate to cardiometabolic risk.

Arachidonic acid induction of Rho-mediated transendothelial migration in prostate cancer

BACKGROUND

Bone metastases in prostate cancer (CaP) result in CaP-related morbidity/mortality. The omega-6 polyunsaturated fatty acid (PUFA) arachidonic acid (AA) and lipophilic statins affect metastasis-like behaviour in CaP cells, regulating the critical metastatic step of CaP migration to the bone marrow stroma.

METHODS

Microscopic analysis and measurement of adhesion and invasion of CaP cells through bone marrow endothelial cells (BMEC) was undertaken with AA stimulation and/or simvastatin (SIM) treatment. Amoeboid characteristics of PC-3, PC3-GFP and DU-145 were analysed by western blotting and Rho assays.

RESULTS

The CaP cell lines PC-3, PC3-GFP and DU-145 share the ability to migrate across a BMEC layer. Specific amoeboid inhibition decreased transendothelial migration (TEM). AA stimulates amoeboid characteristics, driven by Rho signalling. Selective knock-down of components of the Rho pathway (RhoA, RhoC, Rho-associated protein kinase 1 (ROCK1) and ROCK2) showed that Rho signalling is crucial to TEM. Functions of these components were analysed, regarding adhesion to BMEC, migration in 2D and the induction of the amoeboid phenotype by AA. TEM was reduced by SIM treatment of PC3-GFP and DU-145, which inhibited Rho pathway signalling.

CONCLUSIONS

AA-induced TEM is mediated by the induction of a Rho-driven amoeboid phenotype. Inhibition of this cell migratory process may be an important therapeutic target in high-risk CaP.

Description of the Western Sydney and Nepean Blue Mountains local health districts' influenza prevention programme

BACKGROUND

Influenza is a major cause of morbidity and mortality. In 2011, influenza vaccination was provided free for people at greatest risk of severe disease: people aged 65 years and over, Aboriginal Australians 15 years and older, pregnant women, and individuals aged 6 months and over who suffered chronic medical conditions.

AIMS

To evaluate the Western Sydney and Nepean Blue Mountains Local Health District Influenza Prevention Program and to identify some of the enablers and barriers to vaccination in the hospital outpatient setting.

METHODS

Western Sydney and Nepean Blue Mountains local health districts' influenza prevention programme provided influenza vaccine in hospital outpatient settings between 21 March 2011 and 30 June 2011. Accredited nurse immunisers vaccinated 2824 individuals and recorded their primary reason for vaccination. Nurse immunisers were interviewed to identify barriers and enablers to influenza immunisation uptake.

RESULTS

Two thousand, eight hundred and twenty-four doses of influenza vaccine were administered to people at high risk of influenza in four hospitals in the region: two tertiary facilities and two district hospitals. The primary indication for vaccination was chronic disease in 50% and pregnancy in 37%. Estimated direct cost of the programme was $19 per dose.

CONCLUSIONS

A hospital-based influenza vaccination programme can be an effective way to improve influenza vaccination rates among specific population groups at high risk of severe disease with influenza, particularly pregnant women and those younger than 65 years with a chronic medical condition.

Abstract S3-06: Emergence of constitutively active estrogen receptor mutations in advanced estrogen receptor positive breast cancer

Introduction: The lack of estrogen receptor (ER) expression is the primary cause of de novo resistance of breast cancers to endocrine therapy. In contrast, in most cases of acquired endocrine resistance, ER is expressed and other mechanisms of resistance have been proposed, such as ER mutations. Pre-clinical studies demonstrated a small number of specific point mutations that can enhance ER function. However, the studies on clinical samples performed in the 1990's were limited by small sample size, lack of detailed clinical correlation and lacked the sensitivity of next-generation sequencing (NGS). Therefore, in this study we sought to comprehensively investigate the frequency and functional significance of ER mutations throughout the progression of breast cancer from primary disease to advanced metastatic disease using targeted NGS.

Methods: In this retrospective study, a total of 249 tumor specimens were analyzed. The specimens include 134 ER positive and, as controls, 115 estrogen receptor negative tumors. The estrogen receptor positive samples consist of 58 primary breast cancers and 76 metastatic sample. All tumors were sequenced with high coverage using NGS targeting the coding sequence of ER and an additional 181 cancer-related genes.

Results: Recurring somatic mutations at codons 537 and 538 within the ligand-binding domain of the estrogen receptor were detected in ER positive metastatic tumors. Overall, the frequency of these mutations was 12% (95% CI 6%-21%) in metastatic patients compared with none in the primary cases. In total there were 9 recurring somatic mutations; Y537C (11%), Y537N (33%), Y537S (22%) and D538G (33%). In addition in a small number of paired primary and metastatic samples from the same patient, these mutations were found only in the metastatic specimens. In a subset of heavily pre-treated patients the frequency was 20% (5/25, 95% CI 7%-41%). ER activating mutations were not detected in any stage of ER negative disease. ER alterations were not mutually exclusive with any of the other commonly altered genes and of the most frequently altered genes, all but ER alterations displayed similar frequencies across primary and metastatic specimens. Functional studies in cell line models demonstrated that these ER mutations render ER constitutively active and confer resistance to hormone deprivation, tamoxifen and fulvestrant.

Conclusions: Herein, we reveal functional ER mutations as potential drivers of endocrine resistance during the progression of ER positive breast cancer. The absence of detectable mutations in the primary tumors suggests clonal evolution as the mechanism of resistance. Thus, these mutations have the potential to be an important genetic biomarker of endocrine resistance in ER positive metastatic breast cancer and could assist in clinical decision making as disease progresses. Our findings also underscore the value of repeated biopsies of metastatic lesions. Lastly, since the frequencies of these mutations are substantial when sensitive testing methods are used in the correct clinical context, pre-clinical and clinical studies to identify novel therapeutics that can overcome this resistance are warranted.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr S3-06.

Abstract OT3-2-05: Randomized phase II study of fulvestrant with or without ganetespib in patients (pts) with hormone receptor (HR)-positive metastatic breast cancer

Background: In pts with HR-positive metastatic breast cancer, endocrine resistance is a major clinical problem. Ganetespib is a small molecule inhibitor of heat shock protein 90 (HSP90), a molecular chaperone protein that regulates post-translational folding of numerous client proteins including estrogen and progesterone receptor. In preclinical HR-positive breast cancer models, ganetespib impairs endocrine resistance and reduces heterogeneity in the disease control achievable by hormonal therapies.

Trial Design and Eligibility: This is a randomized phase II study designed to evaluate the efficacy of ganetespib in combination with fulvestrant compared to fulvestrant alone. Pts with endocrine-resistant, HR-positive metastatic breast cancer and up to 1 prior line of metastatic chemotherapy are eligible. Endocrine resistance is defined as relapse while on or within 1 year of completion of adjuvant endocrine therapy (ET) or progression through at least one line of ET for advanced disease. Patients are treated with fulvestrant 500 mg IM on Cycle 1 Day 1 (C1D1) and C1D15, C2D1, and D1 of each subsequent 28-day cycle. Ganetespib is administered at a starting dose of 200 mg/m2 IV on Days 1, 8, and 15 of each cycle. Pts undergo optional research biopsies at baseline and time of progression. Pts with accessible disease undergo a required research biopsy on C2D9. Circulating tumor cells (CTCs) and peripheral blood mononuclear cells (PBMCs) are collected at baseline, C2D8, C2D9, and time of progression. Pts who progress on fulvestrant may cross over to the combination.

Aims: The primary endpoint is progression-free survival. Secondary endpoints include safety and tolerability, objective response rate by RECIST 1.1, clinical benefit rate, and overall survival. Correlative aims include comparison of biomarkers on the C2D9 biopsy in pts treated with fulvestrant alone versus the combination of fulvestrant plus ganetespib, analysis of CTCs and pharmacodynamic markers in PMBCs.

Statistical Methods: Pts will be randomized 1:2 to receive fulvestrant alone or the combination of fulvestrant plus ganetespib. The total accrual goal is 71 pts. The expected accrual rate is 3.5-4.5 pts per month over a period of ∼20 months; it is anticipated at ∼15% of pts may be censored for PFS, with similar probability on both arms. There will be 80% power to detect a prolongation of true median PFS from 4.0 months to 8.0 months, using a one-sided 0.05 log-rank test.

Acrrual: To date, 15 of 71 planned pts have been enrolled.

Funding: The trial is supported by a grant from the Susan G. Komen foundation and funding from Synta Pharmaceuticals.

Contact information: nlin@partners.org.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr OT3-2-05.

Abstract P4-01-14: Two-week change in optical tomography predicts residual cancer burden score in women treated with neoadjuvant chemotherapy

Background: A low Residual Cancer Burden (RCB) score after neoadjuvant chemotherapy (NACT) predicts an improved survival in patients (pts) with breast cancer (BC). While an early predictor of tumor response to NACT would allow for treatment optimization, no ideal method exists. Diffuse optical tomography (DOT) is a novel, fast, and low-cost imaging approach that assesses the distribution of water (H2O), oxyhemoglobin (HbO), and deoxyhemoglobin (Hb) concentrations, as a measure of tissue vascularity, without the use of ionizing radiation or breast compression, allowing for safe repeated measurements. We hypothesize that changes in DOT parameters will predict the RCB score following NACT.

Methods: Women with stage II-IIIc invasive BC scheduled to undergo NACT with 12 cycles of a weekly taxane followed by 4 cycles of doxorubicin with cyclophosphamide were enrolled. Treatment with biologic therapies was allowed. DOT assessments were made before starting NACT, 2 weeks into treatment, and before surgery. DOT data were reconstructed into 3D images of the tumor region, from which HbO, Hb, and H2O concentrations were extracted. Final pathology specimens were scored for the RCB index (continuous measure), RCB class (0, 1, 2, 3), and a dichotomized RCB score (RCB class 0 or 1: responders to NACT; RCB class 2 or 3: non-responders). Ki-67 was measured on baseline tumor biopsies and surgical specimens. Correlation analysis, ANOVA testing, and two sample t-tests were used to evaluate the relationship between the 2-week changes in DOT parameters and the RCB score and Ki-67 level.

Results: Since July 2011, we have recruited 24 pts of a total planned accrual of 40. 19 pts have undergone surgery and complete data is available for 13 at this time. Of the 13 pts, 4 had a pCR (RCB 0), 2 had RCB 1, 6 had RCB 2, and 1 had RCB 3. The Pearson correlations between the 2-week change in HbO, Hb, and H2O with the continuous RCB index were 0.76 (p = 0.0022), 0.87 (p = 0.0001), and 0.74 (p = 0.0038), respectively. There was a significant difference in the 2-week Hb change for pts with RCB 0 compared to pts with RCB 1, 2, or 3. There were significant differences in the 2-week change in H2O and HbO for pts with RCB 0 compared to pts with RCB 2. There were also significant differences between DOT parameters by the dichotomized RCB score (table 1). Ki-67 change was correlated with 2-week H2O change (Pearson r = 0.61 p = 0.045).

2-week DOT% change by RCB class and dichotomized RCB score HbOHbOH2ORCB 0-38%-28.5%-6.7%RCB 1-3.9%-2.9%-0.2%RCB 2+2.3%-0.6%+0.7%RCB 3+1.0%+10.9%-0.4%    Responders (RCB 0/1)-26.6%-20%-4.5%Non-Responders (RCB 2/3)+2.1%+1%+0.6%P value0.010.00690.014

Conclusions: Two-week DOT change is an early predictor of response to NACT as measured by the RCB score. We found significant associations between the RCB index and Ki-67 with 2-week changes in HbO, Hb, and H2O. Significantly different changes in DOT parameters were associated with the other RCB classifications. We are analyzing DOT data on the remaining pts and will conduct biomarker assessments of microvessel density changes. Additional pts are being recruited to evaluate DOT's predictive ability by tumor subtype.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-01-14.

Moderate alcohol consumption enhances vaccine-induced responses in rhesus macaques

We have recently shown that chronic alcohol consumption in a rhesus macaque model of ethanol self-administration significantly modulates the serum cytokine profile. In this study, we extended these observations by investigating the impact of chronic ethanol exposure on the immune response to Modified Vaccinia Ankara (MVA). All animals were vaccinated with MVA before ethanol exposure to ethanol and then again after 7 months of 22 h/day of "open-access" drinking of 4% (w/v) ethanol. Our results indicate that animals whose blood ethanol concentration (BEC) chronically exceeded 80 mg/dl had lower CD4 and CD8 T cell proliferation as well as IgG responses following MVA booster than control animals. In contrast, relatively moderate drinkers whose BEC remained below 80 mg/ml exhibited more robust MVA-specific IgG and CD8 T cell responses than controls. To begin to uncover mechanisms underlying the differences in MVA-specific responses between the three groups, we analyzed plasma cytokine levels and microRNA expression in peripheral blood mononuclear cells following MVA booster. Our findings suggest that moderate ethanol consumption results in higher levels of antiviral cytokines and an expression profile of microRNAs linked to CD8 T cell differentiation. In summary, moderate alcohol consumption enhances recall vaccine responses, whereas chronic alcohol intoxication suppresses this response.

Evaluation of Erytra® fully automated analyser for Routine Use in Transfusion Laboratory

OBJECTIVE

To evaluate efficiency and performance of Erytra® analyser in comparison to the reference platform of the NBT immunohaematology laboratory (Bio-Rad ID-System).

BACKGROUND

Moving to automation or semi-automation is a major focus of transfusion centres. The Erytra® (Grifols) is a new fully automated walk-away analyser with high volume processing capacity for pre-transfusion testing, designed to be used with the unique 8-column DG Gel® cards.

STUDY DESIGN AND METHODS

A total of 2201 immunohaematological tests (1041 ABO/D grouping, 1041 antibody screening, 51 antibody identification, 45 newborns (ABO/D and DAT) and 23 crossmatches were performed on 1160 donor/patient whole blood samples. Erytra®'s performance was assessed by means of a stress test replicating the routine work of a hospital laboratory.

RESULTS

Concordant results between the Erytra® and the reference method were obtained in 2195 (99·73 %) of the tests. There were only three discrepancies out of 6246 reactions (0·05%) in ABO/D grouping, all in the reverse group which did not mislead to group identification. Of the 1041 samples screened for antibody presence, Erytra® detected all the relevant antibodies [9 not detected weak prophylactic anti-D were determined to be clinically nonsignificant (<0·1 IU mL(-1) )] while Bio-Rad ID-System missed one anti-e and one anti-Jk(a) . Concordance for D grouping, crossmatching and newborns was 100%. Results of the simulated stress test exercise highlighted the capacity of Erytra® for absorbing into 4 h workloads equivalent to 24 h of routine.

CONCLUSIONS

Grifols' Erytra® analyser showed reliable high sensitivity, velocity and capacity to cope with high workload in the immunohaematology laboratory routine.

Decamethylcyclopentasiloxane (D5) spiked sediment: bioaccumulation and toxicity to the benthic invertebrate Hyalella azteca

Chronic toxicity and bioaccumulation of decamethylcyclopentasiloxane (D5) to Hyalella azteca was examined in a series of spiked sediment exposures. Juvenile H. azteca were exposed for 28d (chronic) to a concentration series of D5 in two natural sediments of differing organic carbon content (O.C.) and particle size composition. The chronic, LC50s were 191 and 857μgD5g(-1) dry weight for Lakes Erie (0.5% O.C.) and Restoule (11% O.C.) respectively. Inhibition of growth only occurred with the L. Restoule spiked sediment with a resultant EC25 of 821μgg(-1)dw. Lethality was a more sensitive endpoint than growth inhibition. Biota sediment accumulation factors (BSAFs, 28d) were <1 indicating that D5 did not bioconcentrate based on lipid normalized tissue concentrations and organic carbon normalized sediment concentrations. Organic carbon (OC) in the sediment appeared to be protective, however normalization to OC did not normalize the toxicity. Normalization of D5 concentrations in the sediments to sand content did normalize the toxicity and LC50 values of 3180 and 3570μg D5g(-1) sand dw were determined to be statistically the same.

Monitoring rainwater and seaweed reveals the presence of (131)I in southwest and central British Columbia, Canada following the Fukushima nuclear accident in Japan

Detailed analysis of (131)I levels in rainwater and in three species of seaweed (Fucus distichus Linnaeus, Macrocystis pyrifera, and Pyropia fallax) collected in southwest British Columbia and Bella Bella, B.C., Canada was performed using gamma-ray spectroscopy following the Fukushima nuclear power plant accident on March 11, 2011. Maximum (131)I activity was found to be 5.8(7) Bq/L in rainwater collected at the campus of Simon Fraser University in Burnaby, B.C. nine days after the accident. Concomitantly, maximum observed activity in the brown seaweed F. distichus Linnaeus was observed to be 130(7) Bq/kg dry weight in samples collected in North Vancouver 11 days following the accident and 67(6) Bq/kg dry weight in samples collected from the Bamfield Marine Sciences Centre on Vancouver Island 17 days following the accident. The (131)I activity in seaweed samples collected in southwest B.C. following the Fukushima accident was an order of magnitude less than what was observed following Chernobyl. Iodine-131 activity in F. distichus Linnaeus remained detectable for 60 days following the accident and was detectable in each seaweed species collected. The Germanium Detector for Elemental Analysis and Radioactivity Studies (GEARS) was modeled using the Geant4 software package and developed as an analytical tool by the Nuclear Science group in the Simon Fraser University Department of Chemistry for the purpose of these measurements.

Apples and oranges: a comparison of costing methods for obesity

Obesity has escalated to epidemic proportions over the past 30 years resulting in increased disease burden and healthcare costs. The aim of this paper was to analyse different costing methods for obesity. Several databases have been searched to identify eligible literature estimating obesity cost. These were categorized into databases, patient-attributable fraction (PAF) and modelling studies. Studies from the United States were used to explore effects of study designs on cost outcomes. Our results show that cost outcomes are largely affected by underlying study designs, such as population size, age, cost categories (medical expenditure vs. total costs), length of the data collection and body mass index cut-offs. Three study types are likely to have an impact on reported costs, with modelling studies providing the most conservative estimates. Database studies can help to increase the overall awareness of the economic burden of obesity. PAF studies can make the obesity disease more tangible by drawing connections to diseases. Decision makers need to be aware of the different purposes and weaknesses of the studies when interpreting cost outcomes. Further research is needed to refine the existing methods and provide high-quality data accounting for the complexity of the disease.

MiR-221 promotes the development of androgen independence in prostate cancer cells via downregulation of HECTD2 and RAB1A

Hormone-sensitive prostate cancer typically progresses to castration resistant prostate cancer (CRPC) after the androgen deprivation therapy. We investigated the impact of microRNAs (miRs) in the transition of prostate cancer to CRPC. MiR-221/-222 was highly expressed in bone metastatic CRPC tumor specimens. We previously demonstrated that transient overexpression of miR-221/-222 in LNCaP promoted the development of the CRPC phenotype. In current study, we show that stably overexpressing miR-221 confers androgen independent (AI) cell growth in LNCaP by rescuing LNCaP cells from growth arrest at G1 phase due to the lack of androgen. Overexpressing of miR-221 in LNCaP reduced the transcription of a subgroup of androgen-responsive genes without affecting the androgen receptor (AR) or AR-androgen integrity. By performing systematic biochemical and bioinformatical analyses, we identified two miR-221 targets, HECTD2 and RAB1A, which could mediate the development of CRPC phenotype in multiple prostate cancer cell lines. Downregulation of HECTD2 significantly affected the androgen-induced and AR-mediated transcription, and downregulation of HECTD2 or RAB1A enhances AI cell growth. As a result of the elevated expression of miR-221, expression of many cell cycle genes was altered and pathways promoting epithelial to mesenchymal transition/tumor metastasis were activated. We hypothesize that a major biological consequence of upregulation of miR-221 is reprogramming of AR signaling, which in turn may mediate the transition to the CRPC phenotype.

Landscape of two-proton radioactivity

Ground-state two-proton (2p) radioactivity is a decay mode found in isotopes of elements with even atomic numbers located beyond the two-proton drip line. So far, this exotic process has been experimentally observed in a few light- and medium-mass nuclides with Z≤30. In this study, using state-of-the-art nuclear density functional theory, we globally analyze 2p radioactivity and for the first time identify 2p-decay candidates in elements heavier than strontium. We predict a few cases where the competition between 2p emission and α decay may be observed. In nuclei above lead, the α-decay mode is found to be dominating and no measurable candidates for the 2p radioactivity are expected.

Impact of temozolomide on gonadal function in patients with primary malignant brain tumors

BACKGROUND

Cumulative exposure to alkylating agents may produce impaired reproductive function. Temozolomide is an alkylating agent approved for treating malignant gliomas.

OBJECTIVE

A pilot study was undertaken to investigate the effects of temozolomide on semen integrity in men with newly diagnosed or recurrent malignant gliomas.

METHODS

Eligible patients had no known fertility problems or impotence. Comprehensive semen analysis and serum sex hormones were obtained at baseline and following 3 and at least 6 months of temozolomide.

RESULTS

Thirteen men were recruited. Mean age was 42 years (28-58). Three had recurrent and 10 newly diagnosed malignant glioma. Four were unable to ejaculate or were azoospermic at baseline. Four provided samples at baseline and after at least 6 months of temozolomide. Five were unable to complete the study. Two of four patients with paired baseline and 6-month samples received 6 months of standard monthly temozolomide. Two patients received standard radiation and concurrent temozolomide followed by adjuvant temozolomide. At 6 months, three of these four patients demonstrated low sperm motility (two low at baseline); three had abnormally low percent normal forms (one abnormal at baseline); two developed abnormally low sperm density. Sex hormone values were normal in all four patients at all time points.

CONCLUSION

Changes in semen analysis parameters following 6 months of temozolomide were observed. The small sample size precludes any firm conclusions regarding the importance and duration of these findings and their relation to temozolomide exposure. With validation in a larger study, these results may have important implications for counseling prior to initiation of temozolomide therapy in these patients.

Abstract P6-12-03: Effects of high dose of bisphosphonate therapy on bone microarchitecture of the peripheral skeleton in women with early stage breast cancer

Background: Randomized studies investigating adjuvant bisphosphonates in women with breast cancer are ongoing. While bisphosphonates would be expected to prevent the deterioration of bone microarchitecture that accompanies hormone or chemotherapy, complete suppression of osteoclast activity for prolonged periods of time can decrease repair of micro-cracks, and possibly lead to decreased bone strength. While bone strength is governed by the amount of bone present, trabecular and cortical components of bone microarchitecture also contribute independently to bone strength. We aimed to characterize the effects of long-term bisphosphonates on bone microarchitecture in women with breast cancer using high-resolution peripheral quantitative computed tomography (HR-pQCT) of the distal radius and tibia.

Methods: We conducted a cross-sectional study involving early stage breast cancer patients treated with bisphosphonates on the S0307 clinical trial. Women were randomized to receive zoledronic acid, oral clodronate or oral ibandronate in doses far higher than those used in osteoporosis treatment as per protocol. After 18–36 months of bisphosphonate therapy, participates underwent a one-time evaluation of areal bone mineral density (aBMD) of the 1/3 radius, lumbar spine, and hip by dual energy x-ray absorptiometry (DXA), and cortical and trabecular volumetric BMD (vBMD) and trabecular microarchitecture of the radius and tibia by HR-pQCT. HR-pQCT measurements were compared to healthy young premenopausal women and age-matched Caucasian women.

Results: Baseline characteristics of the 12 enrolled patients: median age of 53 (range 40–67); white/Hispanics 7/5; pre/postmenopausal 4/8; mean body mass index 28.7 kg/m2 (20.9–34.8); average time on bisphosphonates 20 months (18–30); zoledronic acid/clodronate/ibandronate 5/6/1. The median aBMD DXA T-score of the 1/3 radius, lumbar spine and total hip were normal at +0.3, +0.1, and +0.2, respectively. Mean total, cortical, and trabecular vBMD of the radius as measured by HR-pQCT were 330±71, 905±55, and 146±35 mg hydroxyapatite/cm3, respectively. Mean cortical thickness was 0.803±0.170 mm, and mean trabecular number was 1.9±0.2. Mean total, cortical, and trabecular vBMD of the tibia were 285±54, 880±54, and 150±38 mg hydroxyapatite/cm3, respectively. Mean cortical thickness was 1.135±0.264 mm, and mean trabecular number was 1.7±0.3. There were no statistically significant differences between study group and each control. However, results were more similar to healthy young premenopausal control than the age-matched control.

Conclusion: Women on long-term bisphosphonate therapy for breast cancer had normal aBMD by DXA and normal cortical and trabecular vBMD, cortical thickness and trabecular number at the peripheral skeleton compared to healthy young women and age-matched women. This preliminary data is reassuring for cancer survivors if benefits from this therapy are established in the adjuvant setting.

Abstract PD01-08: Differences in estrogen receptor signaling in non-malignant primary ER-positive breast epithelial cells and breast cancer

Background: The estrogen receptor (ER) is expressed in ∼70% of sporadic breast cancer and activates genes driving cell proliferation and tumorigenesis. We have previously performed genome-wide analysis of ER binding sites in MCF-7 breast cancer cells, and identified distinct mechanisms of ER signaling. We have also previously used EpCAM and CD49f as markers to enrich for viable ER-positive (ER+) cells obtained from non malignant breast tissue. Here, we seek to elucidate differences in ER signaling between non-malignant and ER+ breast cancer cells.

Methods: Primary breast epithelial cells were obtained from patients undergoing reduction mammoplasties and surgical excision of ER+ breast cancer. After dissociation of breast reductions into a single-cell suspension, ER+ mature luminal (ML; EpCAM+CD49f−) and luminal progenitor (LP; EpCAM+CD49f+) subpopulations were obtained by flow cytometry. Following estrogen stimulation, RNA was extracted for gene microarray analysis. ER chromatin immunoprecipitation and DNA sequencing (ChIP-seq) was performed. These results were compared to MCF-7 breast cancer cells.

Results: Reduction mammoplasty and ER+ breast cancer tissues were analyzed, and compared to MCF-7 cells. Gene expression profiles were different between non-malignant tissue and ER+ breast cancer cells following estrogen stimulation, with a 2–3 fold higher number of ER regulated genes in ER+ breast cancer compared to ER+ non malignant cells, and few overlapping estrogen regulated genes. Genes that promotes cell cycling and cell proliferation were downregulated in non-malignant tissue, but were upregulated in breast cancer cells (P &lt; 10–5). CYP1A1, a major estradiol metabolizing enzyme, was upregulated in normal cells but downregulated in ER+ breast cancer cells. Motif analysis of ER ChIP-seq data in normal and ER+ breast cancer tissues demonstrated an enrichment of ER motifs in the overlapping sites and an enrichment of FOXA1 motifs in ER+ breast cancer cells and TCF12 motifs in non-malignant ER+ epithelial cells.

Conclusions: There are contrasting differences in ER signaling between normal mammary and breast cancer cells, with estrogen having anti-proliferative effects in normal luminal cells compared to pro-proliferative effects in breast cancer. ER ChIP-Seq has identified TCF12 as a major co-factor in non-malignant breast tissue whilst FOXA1 is a major co-factor in ER+ breast cancer. Our data provides evidence for key alterations in ER-signaling during tumorigenesis, and identifies potential mechanisms to target cancer specific ER signaling.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr PD01-08.

Abstract P1-07-07: Inflammatory gene expression variations in the interval between core needle biopsy and excisional biopsy in early breast cancer

Introduction: Advancements in molecular biology have unveiled multiple breast cancer promoting pathways and potential therapeutic targets. Large randomized clinical trials remain the ultimate means of validating therapeutic efficacy, but they require large cohorts of patients and are lengthy and costly. An alternative approach is to conduct a window of opportunity study in which patients are exposed to a drug pre-surgically during the interval between the core needle biopsy (CNB) and the definitive surgery (excisional biopsy (EB)). These are non-therapeutic studies and the end point is not clinical or pathological response but rather evaluation of molecular changes in the tumor specimens that can predict response. However, since the end points of the non-therapeutic studies are biologic, it is critical to first define any biologic changes that occur in the absence of treatment. In this study, we compared the molecular profiles of breast cancer tumors at the time of the diagnostic biopsy versus the definitive surgery in the absence of any intervention.

Methods: The study was conducted with DFCI/HCC IRB approval and patient consent. Post-menopausal women with a breast lesion suspected to be cancerous were eligible for this study. We obtained a tissue specimen at the time of a CNB and if determined to be consistent with invasive carcinoma a second specimen was obtained at the time of the EB. We used the Nanostring Ncounter system to study the expression level of 148 transcripts. Since we expected that most of the tumors will be hormone receptor positive (HR+), the library included; genes that have been shown to be prognostic in HR+ tumors (Oncotype DX®, PAM50), estrogen receptor (ER) modulators, ER responsive genes and inflammatory genes. The Wilcoxon's signed rank test was used to evaluate for changes in gene expression levels between the paired samples.

Results: 25 patients were enrolled in this study and paired tumor tissue samples were obtained from all patients. 21 of the paired samples were successfully analyzed by the nanostring system. 86% of the patients are HR+/Her2−. We found that the gene expression levels of 14 out of the 148 genes (9%) did change between the CNB and EB without any intervention (p &lt; 0.05). 8 of these 14 genes can be classified as inflammatory genes that also have known functions in tumor progression. The expression of these 8 genes was upregulated between the biopsies and include; CD68, ADM, CD14, IL6, VEGFA, CD52, CD44 and SNAI1. These changes may be due to an inflammatory response to the CNB. Ki67 expression did not change significantly between biopsies.

Conclusions: In this study we found significant gene expression variations between CNBs and EBs in 9% of the genes tested, without any therapeutic intervention. Our findings suggest that when conducting a “Window of Opportunity” clinical study to evaluate for biomarkers of response or resistance, changes in expression of inflammatory genes cannot be attributed to treatment and a control arm should be considered.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P1-07-07.

Abstract P4-02-07: Early Optical Tomography Changes Predict Breast Cancer Response to Neoadjuvant Chemotherapy

Background: Pathologic complete response (pCR) or a low Residual Cancer Burden (RCB) score following neoadjuvant chemotherapy (NACT) predicts a superior survival in breast cancer (BC) patients. An early predictive marker of tumor response during NACT would provide a way to optimize treatment for non-responders; however, no ideal technology currently exists. Diffuse optical tomography (DOT) is a novel, fast, safe, and low-cost technique that uses near infrared light to provide 3D data on tissue vascularity without the use of radiation, making it a promising technology for assessing early tumor response to NACT. We hypothesized that a 2-week change in DOT parameters would predict response to NACT as measured by the RCB score.

Methods: Women with stage II-IIIc invasive BC scheduled to undergo NACT with 12 cycles of a weekly taxane followed by 4 cycles of doxorubicin with cyclophosphamide (AC) were enrolled. Treatment with additional biologic therapies was allowed. DOT measurements were made before starting NACT, 2 weeks into treatment, and before surgery. Concentrations of oxyhemoglobin [HbO2], deoxyhemoglobin [Hb], total hemoglobin [HbT], and tissue scattering (SC) were measured by DOT. Final pathology specimens were scored for the RCB index (continuous measure), RCB class (0, 1, 2, 3), and a dichotomized RCB score (RCB class 0 or 1: responders to NACT; RCB class 2 or 3: non-responders). Correlation analysis, ANOVA testing, and two sample t-tests were used to evaluate the relationship between the two-week changes in DOT parameters and the RCB score.

Results: Since July 2011, we have recruited 11 pts, of whom 7 have undergone surgery. Complete data is available for 6 pts. Two of 7 pts had a pCR (RCB 0), 1 had RCB 1, 3 had RCB 2, and 1 had RCB 3. The Pearson correlation between the 2-week change in [Hb] and the continuous RCB index was 0.94 (p = 0.0047), and that between the 2-week change in SC and the RCB index was 0.93 (p = 0.0073). At 2 weeks, the [Hb] decreased by 6.7% for pts whose pathology demonstrated an RCB 0 (pCR), 1.8% for RCB 1, 0.6% for RCB 2, and increased 0.7% for RCB 3. ANOVA and Tukey testing demonstrated a significant difference in the [Hb] change for pts with RCB 0 compared to pts with RCB 1, 2, or 3 (p &lt;0.05). At 2 weeks, SC decreased by 26.5% for pts with RCB 0, 19.3% for RCB 1, 3.7% for RCB 2, and increased by 25.1% for RCB 3. There was a significant difference in the SC change for pts with RCB 0 compared to pts with RCB 3 (p &lt;0.05). Responders (RCB 0/1) had a 5% decrease in [Hb] at 2 weeks compared to non-responders (RCB 2/3) who had a decrease in 0.18% in [Hb] (p = 0.0045), and responders had a 24% decrease in SC compared to non-responders who had an increase in 6% (p = 0.044).

Conclusions: DOT change is an early predictor of response to NACT as measured by the RCB score. We found a significant linear association between the RCB index and the 2-week change in [Hb] and SC. Significantly different changes in DOT parameters were associated with the other RCB classifications. Additional recruitment is ongoing and differences by tumor subtype will be evaluated.

*These two authors contributed equally to this study

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-02-07.

Learning Disability Liaison Nursing Services in south-east Scotland: a mixed-methods impact and outcome study

BACKGROUND

There have been significant concerns about the care and treatment of people with intellectual disabilities (ID) when attending general hospitals, which have led to inquiries that highlight service and systems failures. One response has been the development of Learning Disability Liaison Nursing (LDLN) Services across the UK that aim to ensure that additional, specialist support is available for patients, their carers and general healthcare professionals.

METHODS

A mixed-methods study to investigate the impact of LDLN Services across four Scottish NHS boards was undertaken. In total, 323 referrals made over 18 months were analysed along with qualitative data drawn from interviews and focus groups with a sample of 85 participants including patients with ID (n = 5), carers (n = 16), primary care healthcare professionals (n = 39) and general hospital professionals (n = 19) and learning disability liaison nurses (n = 6).

RESULTS

The referral patterns to the four liaison nursing services closely matched the known health needs of adults with ID, with common admissions being due to neurological, respiratory and gastrointestinal issues. The LDLN role was seen to be complex and impacted on three key areas: (i) clinical patient care; (ii) education and practice development; and (iii) strategic organisational developments. Specific patient outcomes were linked to issues relating to capacity and consent to treatment, fostering person-centred adjustments to care, augmenting communication and the liaison nurses acting as positive role models and ambassadors for people with ID.

CONCLUSIONS

The LDLN Services were valued by stakeholders by achieving person-centred outcomes. With their expert knowledge and skills, the liaison nurses had an important role in developing effective systems and processes within general hospital settings. The outcomes highlight the importance of supporting and promoting LDLN Services and the challenges in delivering the multifaceted elements of the role. There is a need to take account of the complex and multidimensional nature of the LDLN role and the possible tensions between achieving clinical outcomes, education and practice developments and organisational strategic initiatives.